Uncharted waters: Life and death in ICU
By Dr. Tony Johnson
October 21, 2009
This isn’t going to end well, I thought.
The five of us stood in a semi-circle in ICU, trying to figure out what to do. Between us there must have been 30 years of clinical expertise at least, and we were at a loss. Among our number was an intern – a new veterinarian graduate from last year, the greenest of us all but could bring fresh knowledge to the problem, and had not yet felt the heavy chains of burnout. There was a resident, seeking advanced training in internal medicine in order to become a specialist through a 3-year rigorous program. And then there were the specialist ourselves: me, in critical care; a surgeon (whose case it was to begin with); and an internist, or internal medicine specialist. (Internists, often confused with interns, deal with the long-term sick.
When the patients get really good and sick they usually get me involved. I have no long-term memory, so after I attempt to put the fire out, the patients usually go back to either an internist or their regular veterinarian for afters.)
We were all trying to solve the Trevor problem.
Trevor was our collective patient, a middle-aged and sweet dog who had diabetes and had recently undergone surgery for a liver biopsy and removal of his diseased spleen. He was not doing well, not doing well at all, and we were trying to find out a way to help him. At surgery, we had placed a feeding tube into his intestine to aid in the provision of nutrition. He had not eaten for several days before surgery, and it wasn’t looking like he was interested in ordering Chinese takeaway any time soon. He was also leaking a thick, bloody fluid that looked like tomato soup from a large abscess on his side and he was in extreme pain despite the cocktail of analgesics that were dripping into him.
Our current problem was his climbing white blood cell count and the pain. Trevor, as sweet as he is, was a mess, and he was our mess.
When faced with a sick patient (a really sick patient, not just “oh, I broke a toenail, thanks for asking”) medical people (both human and veterinary, and for all I know it slimy 8-legged doctors on Alpha Centauri) formulate what is called a problem list. Simply stated, this is a running tally of all that separates a patient from his or her normal state; their problems. It is made up of any number of abnormalities, from things that have gone wrong on paper (like lab tests) to naughty things that the patient is doing, like vomiting, having cancer or being anemic. This deceptively simple concept is the key to imposing some order on the chaos that can come from any medical crisis.
If you have a truly sick patient, and this selfsame sick patient starts to accumulate problems like a light bulb draws moths, it is easy to become overwhelmed and lose site of what is killing the patient in the face of all that stuff. The temptation is there to just throw up your hands and say “he’s too sick – I give up!”
The creation of a problem list allows you to quantify what is wrong, prioritize it and start chipping away at it.
Trevor’s problem list was growing exponentially, and we were waiting an interminable amount of time for the biopsy.
These types of cases are a terrible gamble for owners; we go in, remove what we hope is the root of the problem, ship them back to ICU and wait for the results with bated breath. If something goes wrong during the stay in ICU after surgery, things get really nasty. There seems to be a collective concept (probably deeply imprinted on us by too many hours in front of the TV) that everything will be fine after surgery; that stuff is fixed. Even surgeons themselves have an adage; a chance to cut (surgical parlance for performing surgery) is a chance to cure.
But from my perspective, sometimes that is exactly the spot where the problems begin.
Patients with complications after surgery can amass huge medical bills that make the surgeon’s fee look like chump change. ICU fees for post-operative care can run into the thousands, and without biopsy results in hand owners often don’t know if they are putting their pets through the medical grinder (and spending money like water) in vain. This was our precarious position right now. Luckily, in a perverse way, the discovery of the abscess on his side was helpful to us, and hopefully helpful to Trevor himself. We had been searching for a cause for the pain and skyrocekting white blood cell count (abbreviated to WBC, and not always associated with infection but usually a good bet that it is lurking somewhere). The abscess, which drained while we were examining him and changing his bandages, was likely the source of all of his new problems. The hope was that getting the infected goo out of there would bring about the change in course that we had hoped to see. He had been in ICU nearly a week already, and there had not been much of a light to guide us since surgery. With the discovery of the source of his fever, pain and climbing WBC, we thought we saw some small and distant twinkle in the dark; a beacon saying shore might be close at hand.
Once again, hope started to creep into ICU.
I have learned that this is not a good thing, despite whatever positive powers hope is said to have. Hope needs to be there; hell, hope is a natural part of our human makeup that helps us cope with situations like this. But hope too soon in the game is toxic. Hope, when your team is winning by a narrow margin before halftime, is too fragile a thing to be worth a tinker’s damn. It is too often smashed, and the sharp little shards it leaves behind are apt to do some damage. Hope, in my opinion, should be saved for when the opposing team is thoroughly vanquished and there are 0:02 left on the clock; then it can be let out and acknowledged. Hope needs to have reality to back it up or it boomerangs on you.
Just as the surgeon was cleaning up the abscess and draining the fluid that was making Trevor sicker than he should have been, word came through from pathology; hemangiosarcoma.
Cancer is bad; hemangiosarcoma is worse.
It is an unusually ill-tempered and vicious type of cancer that arises from blood-forming organs like the spleen, which is where it was found in Trevor’s case. There are many types of cancers, and they are as varied a people are. Some are pokey and slow-growing, unlikely to kill the host before they die of some other ailment (like prostatic cancer in humans), while others are voracious black storms, devouring the host and spreading to every available niche with frightening speed.
Hemangiosarcoma was of the latter variety. Most patients live, on average, 3 months or so after a diagnosis is made. With the addition of medications to control cancer (chemotherapy) this can be extended by a few more months, but it is not the kind of cancer for which we can typically expect many months or years of good-quality life. It seems like the punch line to a rude joke, but it is bad cancer.
I am not sure what will happen; his family is on the way to discuss his present and his future. They have already expressed a reluctance to euthanize (the owner stated he would do himself in before he made the call to end Trevor’s life), but sometimes hearts and minds can change when faced with hard data and short survival times.
We have done a good job (I hope) of making Trevor as comfortable and cared for as we could. I hope, too, that he has some dignity left and he has not been in a great deal of pain. I know what I would do in these circumstances; lurching off course in ICU, flying a flag with a leering skull and crossbones. But I don’t know what Trevor’s family will do. At times like this, most would make the decision to have Trevor euthanized, to end his suffering. But not all. And the University is not like most veterinary hospitals; the families have been through several levels of the medical hierarchy before getting here, a process which usually leaves (for better or worse) the supremely dedicated, in some cases the pathologically attached and almost always the financially independent.
I have been pushed to go further a few times in my career, and this is where you tap into all sorts of skills you may not have known you were in possession of. And, at the edges of what most would consider the normal veterinary medicine map of the world, the usual right-vs.-wrong rules fail to apply. Here there be dragons. What if they decide to go ahead and he beats the odds and lives another five years of good life? What if they slog it out in ICU for 7 more days, spend countless thousands, only to lose him to infection, blood loss or one of the other myriad disorders that can make you shuffle off this mortal coil? Which was the right decision? The answer only comes after all is said and done, and whatever ship has sailed has come into port.
As a doctor, you also find you can do things you didn’t know you could in a crisis, but it comes at a price; am I doing the right thing? And if you are – for whom? The patient? The family? Me? The world at large? Amazing how such a simple little thing as a dog with an abscess in ICU can have global ramifications if you let it out far enough.
They will be here soon. I only hope they make the right call.
Whatever that is.
First of all, I pray for Trevor and his family and doctors. It’s a tough call all the way around.
Next, please let me tell you how much I enjoy reading your articles - not only are they incredibly interesting and thought provoking, you have a style of “talking” to your readers and I find that very engaging.
Lastly, I have been where Trevor and his family are/were with my oldest cat. Without too many details, she was a victim of the poison food late in 2006, coupled with Metacam blowing out what was left of her kidney function. Fortunately, I live close to a university teaching hospital so had some amazing people (and resources) available to us. She spent 2 weeks in ICU and has since had two surgeries, many hospitalizations and procedures and my retirement savings is gone. (Not all of us are independently wealthy) But I simply did not have it in my heart to euthanize a cat who was fighting so very hard to live and who was showing stability, if not improvement. There have been many times that I’ve had to make a decision to continue treatment (she stops eating when she is sick so we’ve had feeding tubes four times) or have a surgery done (she had adhesions from the first surgery which totally messed up her stomach and intestines). Her medical issues are complicated and treating her is a balancing act extraordinare, but I wouldn’t do anything differently now.
She is still with me,considering that she battles liver disease and kidney failure, she is a tough old catgirl who fights hard and I will fight with her as long as she asks me to.
But each day is a bonus and she gives me so much, teaches me so many lessons . . . I am very grateful to have her with me.
To all of you on the “front lines” - thank you for doing what you do and for caring so much for our critters. When her internal medicine resident finished and left, I got a lovely message from her sharing just how much my cat had taught her, too, and not just about medicine.
I look forward to reading more and blessings and comfort to Trevor and his people.
Comment by catmom5 — October 21, 2009 @ 6:17 am
catmom - thanks for your kind words and for sharing your story. I am glad things worked out for you and your cat. You are the sort of people that make the job easier; smart, lucid and able to make decision. Thank you as well.
Comment by Dr. Tony Johnson — October 21, 2009 @ 7:22 am
Wow, Dr. Tony … just wow. I hope for the right outcome for Trevor and his family, even if it’s not the outcome all are hoping for. (Having just been through this, I know “right” and “hoped for” aren’t the same.)
And it does sure make me feel a lot better about McKenzie back at the veterinary hospital for more rads today. Even if she DOES need surgery, I know what she and I are facing are nothing compared to this.
So I’m going to quit stressing so much and just work it through.
Good for Purdue U for bringing you on staff this year! I know all the patients, clients, colleagues and students are benefitting.
Comment by Gina Spadafori — October 21, 2009 @ 7:48 am
We are going forward - they have full informed consent, and know the odds are against us, but we are forging on. The little guy is actually doing better today.
Comment by Dr. Tony Johnson — October 21, 2009 @ 8:45 am
I pray for Trevor to soon have more good days than bad…glad to hear he is doing better today…and hope that continues…
Comment by Carol V — October 21, 2009 @ 8:59 am
My prayers for Trevor and his family….
Thank you for writing this…it is what I went through with my old boy, Gator. One day no mass…the next day it seemed, a very definitive mass in his abdomen. I scheduled appointment with UCD-VMTH. I was not overly worried, I had seen something similar with an old old dog of mine. This time not so good. Hemangiosacrcoma….and it was not resectable….it was pretty much everywhere in his abdomen. So they sewed him back up. The night he came back home, he started vomiting, seriously….pancreatitis. One of the side affects from trying to remove the tumor, irritation of the pancreas. Back to emergency that morning. I knew I was faced with the decision that we all have had to do at some point. His attending vet and I discussed all the options, stabilizing in ICU….but the big monster was the cancer…..So…. I let him go.
The folks at UCD-VMTH are a fantastic group….similar to what you describe at Purdue. It sounds like they have added a terrific veterinarian to the group there.
The choices and the decisions….they are never easy……
Thank You…..TEH
Comment by TEH — October 21, 2009 @ 9:07 am
Hemangiosarcoma - uugh! My cocker spaniel died from this cancer. He was fortunate to be relatively asymptomatic until the day he died. My vet cried and gave me great big bear hugs when he learned of Alex’s passing. The treating vet (at an emergency clinic) was a complete jerk who couldn’t tell me what was wrong with my dog but counseled me to euthanize him because whatever it was “was really bad and he’s not coming back from it”.
Thanks, Dr. Johnson, for honoring the wishes of Trevor’s family, even if you’d make a different decision if he were your dog. It really does make all the difference in the world when you know your vet is on your side.
Comment by Sherron — October 21, 2009 @ 1:16 pm
When I read that a “diseased spleen” had been removed, my first thought was “hemangio.” It’s sad, isn’t it, that such an insidious disease is so familiar to us Flat-Coat owners that we have shortened it into a nickname of sorts. Cancer is awful, but hemangio is particularly vicious.
I disagree about hope though. Without hope at the most improbable times, we’d all go insane. Two dogs that should be dead by any experts opinion lay at my feet. My 15+ YO has been treated for chronic renal failure for the last 2 1/2 years. Her BUN, although awful, has held steady as has her awful creatinine level. She’s a happy dog and I greet every day with her with “I’m so glad you’re still here.” (Supplements, sub-Q fluids and Azodyl. And lots of love.)
My other guy was Dx’d with histiocytic sarcoma at 6 YO and was given a prognosis of 3 - 6 months…. two years ago. Yes, we treated aggressively and spent (mumblety) thousands of dollars, but once you’re into it 2 grand just getting the thing Dx’d, why the heck not go all the way? Had to sell some cherished possessions and eat lots of peanut butter along the way, but to us, it was worth it. (And, boy have I learned about nutrition and supplementation!)
Of course, the sibling to “hope” is “denial.” The HS tumor is back and I almost let it go too long before seeking help because I convinced myself it was a soft-tissue injury. Luckily so far, chemo has been effective at keeping the tumor at bay and thus increasing the dog’s comfort significantly. (Knock on wood.)
Gina, you know my thoughts are with you as you work through whatever’s going on with McK. Jester sends her a slurp.
Comment by Deanna — October 21, 2009 @ 5:03 pm
My heart aches for Trevor and his family. I lost my much-loved 10 year-old Lab to hemangiosarcoma a few years back. Much like TEH’s story above, Dixie was seemingly healthy; her semi-annual exam 4 months prior showed no sign of masses. Then WHAM—I came home from work to find her flat-out shocky, gums pale. Off to the vet—only to find a large hemangiosarcoma with a belly full of blood; it had already ruptured. And to top it off there were mets in both lungs on x-ray. So we sadly decided on euthanasia. So whatever the outcome, my thoughts are with the family, and with you, for staying the course with them.
Comment by Shellie — October 21, 2009 @ 5:15 pm
I’m so glad they have you on their & Trevors side ! I know this is a horrible diagnosis,but knowing everyone is pulling for him may make a big difference timewise. Its very hard to switch gears gears mid treatment. When you are trying to do everything to save them, its hard to know when to stop.
Comment by Leslie K — October 21, 2009 @ 6:19 pm
Any news on Trevor today?
Comment by catmom5 — October 22, 2009 @ 6:17 am
Trevor is hanging on but seems to acquire 2 new problems for every one that resolves. I just talked to the student on the case (who is battling a major case of sleep deprivation from being by Trevor’s side at the same time as he juggles other cases) and things are…stable. Sorta. Hour by hour is how these sorts of scenarios go, until they resolve one way or another. The student asked me yesterday if there was a possibility that Trevor could go home, and I said “yes, but…” The ‘but’ is the hard part right now.
Comment by Dr. Tony Johnson — October 22, 2009 @ 6:51 am
Hugs to Trevor and his family. They are doing their best, and so are you. I hope fate intervenes and some good news comes their way.
Comment by Susan — October 22, 2009 @ 8:44 pm